We’ve written several pieces about testosterone in the past few years, so we’ll refer back to some of our previous articles today and bring in some new information. We at QueerDoc strongly believe there is no one way to be trans. If you decide that you want to change your body or change how your body may be perceived, taking hormones is an option, but it is not the only option (we’ll be talking about tips and tools for a way to express your gender without hormones in a couple of weeks.) If you decide that taking hormones might be a part of what you want, you’ll have several decisions. For our patients, we dedicate significant time in the first appointment to discussing those decisions, and we’re always happy to discuss risks, benefits, and what-if questions about gender affirming care…
Content advisory: anatomical terms, reproduction and sexual health talk, mention of needles and injections
On today’s agenda we have:
- Informed Consent
- What are the risks of taking T?
- What will happen to my body?
- I don’t like needles. Do I have to do injections?
- Why can it be so flippin’ hard to get T?
Informed Consent
Informed consent is an ethical and legal responsibility of your provider. It means that your provider gives you enough information about your medical options, along with the alternatives to those options, for you to be able to decide what you want to do. It also means that your provider is supposed to make sure that you understand the risks and benefits of the options and that you both have the capacity to make medical decisions for yourself and the autonomy to do so. Your autonomy is very important to us here at QueerDoc, and central to our practice of medicine is the acknowledgement that patient autonomy has historically been denied (and continues to be denied) to many populations as a form of control and colonization. For more information, read our short description of an informed consent model.
ALL THE T
All The T is our one-pager description of things you need to know about starting testosterone, including the expected changes to your body and when they are likely to happen. We recommend checking it out! We share this timeline on that page, too. We also made a video about the changes that happen in the body on testosterone.
Testosterone Risks (and Benefits)
In last week’s blog, we discussed some of the hormone pathways in the body. One of the big takeaways is that sex steroid hormones like testosterone affect nearly every body system and are pretty complex. It’s important to know and understand that taking T cause changes that you can see, feel, and hear, like hair growth, oilier skin, and a deeper voice, but also ones that you can’t see. Some of these changes may negatively impact your health, and we might not know about all of the possible changes. Of course, some of these changes are exactly what you’re looking for, and isn’t that great?!
Heart Health (Cardiovascular)
See our testosterone and cardiovascular risk and our cardiovascular risks with HRT blogs for in-depth discussions of how testosterone may affect your risk for cardiovascular diseases. Our overall take is that taking testosterone does not appear to change your overall risk of cardiovascular disease, especially when we consider that gender affirming care can lower total stress, which is a disease risk all by itself. Taking T may also increase your risk of diabetes, which can impact your cardiovascular risk.
IMPORTANT: Your overall cardiovascular risk is impacted by a lot of factors, including your weight and how much of your weight is muscle vs. fat (and what kinds of fat,) your diet, whether you use alcohol, tobacco, or other substances, legal and illegal, how much activity you get on a regular basis, and your genetics. Testosterone changes some risk factors in a positive way and others in a negative way. For example, your LDL (a kind of cholesterol that is bad for heart health) may increase on testosterone. At the same time, you may lose body fat and have increased muscle mass, both of which are good for heart health. Your doctor can help you understand your overall cardiovascular risk and how it might change on T.
Thick Blood
Testosterone changes how your body makes blood cells, and can increase both the number of red blood cells in your body and change how those cells carry oxygen. We track the volume of red blood cells with the hematocrit lab. We track how oxygen is carried by those cells with the hemoglobin lab.
If your body makes too many red blood cells (high hematocrit) your blood may become thicker. This makes your heart work harder and increases your cardiovascular risk. If your hemoglobin is high, you may experience dizziness, bruise easily, and be tired. You may also be at higher risk of blood clots, which can be very dangerous.
Often, people taking testosterone are encouraged to donate blood to help prevent or manage this risk.
Reproductive and Sexual Risks
We’ll talk in-depth about contraception while on testosterone next week.
Testosterone should not be used by anyone who is pregnant.
Important: there are no guarantees about current and future fertility while taking testosterone.
- many people stop having monthly bleeding while on testosterone
- that doesn’t mean that ovulation stops
- if ovulation does stop, and the person wishes to get pregnant, it might not start again when testosterone is stopped.
IF:
- you take testosterone
- AND you have a uterus and ovaries
- AND you don’t want to get pregnant
- AND there’s any chance of sperm/semen being near your genitals
- USE CONTRACEPTION
Sexual Health Risks
Bodies with vaginas may experience thinner and drier vaginal skin (called vaginal atrophy,) along with less production of lubrication while on testosterone. This can be uncomfortable, and may make it more likely that small tears in the tissue occur during sexual activity. These tears can put you at higher risk of sexually transmitted infections. The pH of the vagina may also change, making infections such as bacterial vaginosis or yeast infections more likely. Your provider can prescribe localized estrogen that can help protect vaginal tissues without significantly increasing estrogen levels in the body overall.
Forms of Testosterone – What If I Don’t Want To Do Injections?
There are several forms of testosterone available. Each has their own pros and cons.
Most people inject their testosterone. We recommend sub-q injections rather than intra-muscular. This blog talks about why we do so.
We discuss how to do self-injections here. Dr. Kevin Hatfield has also posted videos on YouTube about injections:
Fenway Health has published a downloadable guide.
We also really love our sub-q unicorn graphic.
Other Forms of Testosterone
- Topical gel (and other preparations)
- Patches that you stick on your skin
- Implantable pellets
- Oral and nasal preparations
We wrote a whole blog about oral and nasal T in 2021.
Why Can It Be So Flippin’ Hard To Get T?
We don’t like it, but testosterone is a Schedule III drug, which makes it a controlled substance. The federal government ranks drugs according to their risk of abuse or dependence. Testosterone, along with anabolic steroids, which are man-made versions of testosterone (roughly,) are considered to have a low to moderate risk of dependence, but a higher risk of misuse/abuse than some other drugs.
Until recently, federal laws required an in-person medical visit to legally prescribe testosterone. The expansion of telehealth due to COVID changed that, and we can legally prescribe T without being in the same room with you. There is some risk that laws may change again, and make it harder to prescribe T, but we advocate for continued telehealth prescription.
Some states require two visits before a testosterone prescription may be given (Wyoming.)
Some states track testosterone prescriptions and/or require the provider and pharmacist to check a centralized database of controlled substance prescriptions. This is largely used to prevent opioid abuse, but testosterone may be among the tracked medications. Some states may also require specific licensing for providers who wish to prescribe testosterone.
These regulations can explain why it can be hard to get testosterone via mail order, or why it may take longer to get your first T prescription filled. Check out our Pharmacies page for some online pharmacies that we regularly work with for mailed prescriptions.